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HomeMy WebLinkAboutApplicationGarfield County Community Development Department 108 8'h Street, Suite 401 Glenwood Springs, CO 81601 (970) 945-8212 www.garfield-county.com GARFIELD COUNTY r'n"111l Nfry WifiiiikWISTRUCTION • New Installation WASTE TYPE • Dwelling 0 Transient Use RECEIVED APR 192018 ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION 0 Alteration I r-' Repair O Comm./Industrial 1 0 Non -Domestic 0 Other Describe INVOLVED PARTIES Property Owner: rAk-N E. frtilgore4 +, Phone: IVO ) Alk/�� ,58 Mailing Address:cO /304. B' 11EW C, STLE , co 8 / i Email Address: 1`fJ`t C� ontractor: Mailing Address: WI Aleut/0/ Phone: (CPO ) 846 11555 Po 2( IR SILT, () a er, S2 Email Address: CL+,_Q kr 01.1.61 -D F 7 rY S VL lc) H Engineer: Phone: (___) Mailing Address: Email Address: PROJECT NAME AND LOCATION Job Address: i46 (ICU Mit ""F- killel''"YrrACtE RA -1) ii[9 O\ o Cor Assessor's Parcel Number .[00c3W(, G r «E 1 Lot Block Building or Service Type: g€-51 lir tel - #Bedrooms: _ 1 Garbage Disposal Y N) Distance to Nearest Community Sewer System: 3 r iiL _S Was an effort made to connect to the Community Sewer System: N0 Type of OWTS U Septic Tank ❑ Aeration Plant 0 Vault J 0 Vault Privy Composting Toilet � I O Recycling 0 Pit Privy [ ❑ Incineration Toilet 0 Other O Recycling, Potable Use Ground Conditions O Chemical Toilet Depth to 10 Ground water table 45 er Percent Ground Slope Final Disposal by ip Absorption trench, Bed or Pit ` 0 Underground Dispersal I0 Above Ground Dispersal O Evapotranspiration 0 Wastewater Pond ❑ Sand Filter Water Source & Type ❑ Other ■ Well j ❑ Spring t 0 Stream or Creek f fl astern O Community Water System Name Effluent WiII Effluent be discharged directly into waters of the State? 0 Yes A No CERTIFICATION Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and additional test and reports as may be required by the local health department to be made and furnished by the applicant or by the local health department for purposed of the evaluation of the application; and the issuance of the permit is subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations made, information and reports submitted herewith and required to be submitted by the applicant are or will be represented to be true and correct to the best of my knowledge and belief and are designed to be relied on by the local department of health in evaluating the same for purposes of issuing the permit applied for herein. I further understand that any falsification or misrepresentation may result in the denial of the application or revocation of any permit granted based upon said application and legal action for perjury as provided by law. I hereby acknowledge that I have read and understand the Notice and Certification above as well as have provided the required information which is correct and accurate to the best of my knowledge. rCAtC4_MA/ Property Owner Print and Sign Date OFFICIAL USE ONLY chaa, LAI R/ 18 4.245. 013, -v ' ioce I Special Conditions: Permit Fee: 'zPI,3.©O Perk Fee: (30 1)lam. Tota FFe}es: ( 4S. Feej Paid: QO "_Q2 , Building Permit Septic SSeep�tii-c(Perrmmiit: Issue 0 te: Balance Du OO BUILDING/ PLANNING DIVISION: ►/'i i Signed Approval Date